BVA9508004 DOCKET NO. 93-14 776 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office and Insurance Center in St. Paul, Minnesota THE ISSUE Entitlement to service connection for a cervical spine disorder. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD Richard E. Coppola, Associate Counsel INTRODUCTION The veteran served on active duty from October 1942 to February 1946. This matter came before the Board of Veterans' Appeals (Board) on appeal from a rating decision of April 1992 from the St. Paul, Minnesota, Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for post-traumatic degenerative arthritis of C6-C7, with fusion of C5-C6. REMAND The veteran's service medical records disclose that he was reportedly having back trouble in July 1944. Later in 1944, he was seen for complaints of a low back ache and the diagnosis was lower lumbar strain. Subsequent X-ray examinations in October and December 1944 did not reveal abnormal lumbar or lumbosacral pathology. In January 1945, the veteran was seen for complaints of backache. Report of medical examination at discharge was negative for musculoskeletal defects. At the personal hearing, the veteran testified that his cervical area began bothering after carrying heavy backpacks on long hikes. Transcript, pp. 2, 3 (Feb. 1993). He testified that he never complained of low back pain either during active duty or subsequent to separation. Tr., at 3, 6. The veteran indicated in his December 1992 notice of disagreement that the initial injury was in the area between his shoulder blades. In support of his claim is a March 1992 statement apparently signed by Peter A. Schmitz, M.D., which indicates that he initially treated the veteran in May 1977 following a motor vehicle accident. Dr. Schmitz stated that X-rays taken in 1977 revealed severe, post-traumatic, degenerative arthritis at C6-C7, with apparent fusion of C5-C6, and that "[t]his is consistent with his injury in the service in 1944." The details regarding the nature and extent of this post-service injury are uncertain. The RO denied service connection on the basis that there is no evidence of injury during active duty, or evidence of a cervical disability on the initial post-service VA examinations. A review of these examination reports shows that the veteran complained of pain between the shoulders and low back on VA examination in April 1948, and pain in the interscapular region on VA examination in May 1953. The veteran has indicated that he initially injured his cervical area during active duty and that the symptoms became increasingly severe since separation. The veteran and his representative argue that the evidence of record submitted by the veteran, including the statement of Dr. Schmitz, renders the claim well- grounded. They also argue that the veteran should have been afforded a VA examination to determine the nature of his current cervical disorder. Under the circumstances of this case, the Board is of the opinion that additional assistance is required. The case is REMANDED to the RO for the following actions: 1. The veteran should identify the names and addresses of any medical care providers, VA or otherwise, who have treated him for symptoms of the cervical area since separation from active service. After obtaining any needed authorization from the veteran, the RO should obtain copies of all these records. 2. The veteran should submit a written authorization for the release of all records from Peter A. Schmitz, M.D., 2014 South Sixth Street, Brainerd , Minnesota, 56401. The RO should then request copies of all records of treatment of the veteran by Dr. Schmitz, particularly those associated with a 1977 motor vehicle accident. The veteran should provide the name and address of any other medical care providers that treated or evaluated him for injuries sustained in that accident. After obtaining any needed authorization from the veteran, the RO should obtain copies of all these records. Any evidence obtained should be associated with the claims folder. 3. The veteran should then be afforded a VA orthopedic examination to determine the nature and extent of any cervical disability. The scope of the examination should be broad enough to cover all residual conditions which are suggested by the veteran's complaints, symptoms or findings. The examination should be conducted in accordance with the Physician's Guide for Disability Evaluation Examinations. The physician must be provided the claims folder for review in connection with the examination. The extent of functional loss, including that which is due to pain consistent with the objective findings, should be reported. The physician should express opinions based on the available evidence in the claims folder whether a chronic cervical disability was incurred due to the reported in-service injury and whether any current cervical disability is the result of post- service injuries, including those sustained in the 1977 automobile accident. The physician should give reasons for the opinion(s) and cite the evidence relied upon and/or rejected in forming the opinion(s). 4. When the above development has been completed, the case should be reviewed by the RO. The rating decision should reflect consideration of all potentially applicable criteria. The veteran and his representative should then be furnished with a supplemental statement of the case which summarizes the pertinent evidence, fully cites the applicable legal provisions not previously provided, and reflects detailed reasons and bases for the decision. They should then be afforded the applicable time period to respond. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further consideration, if appropriate. The veteran need take no action until he is further informed. The purpose of this REMAND is to obtain additional information and to ensure due process of law. No inference should be drawn regarding the final disposition of the claim as a result of this action. THOMAS J. DANNAHER Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This action has been taken in accordance with the Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 303, 108 Stat. 4645, ___ (1994), and is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1994).